Endovascular treatment of a blunt thoracic aortic injury in adolescents: a case report

Introduction

Blunt thoracic aortic injury (BTAI) in adolescents represents an uncommon but serious condition, most frequently caused by high-energy trauma such as motor vehicle collisions or high-altitude falls. A substantial proportion of affected individuals succumb to their injuries at the trauma scene (1). These injuries typically present with concomitant severe multisystem trauma, which not only complicates BTAI management but also contributes to the high perioperative mortality associated with surgical repair (2). Current therapeutic approaches for BTAI encompass conservative management, open surgical repair, and thoracic endovascular aortic repair (TEVAR). Since receiving Food and Drug Administration (FDA) approval in 2005, TEVAR has gained widespread acceptance in adult vascular surgery for BTAI management (3). However, its application in adolescent populations remains limited, with only sporadic case reports and small-scale studies available in the literature (4-6). The minimally invasive nature and targeted therapeutic efficacy of TEVAR make it particularly advantageous for adolescents presenting with polytrauma. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-233/rc).

Case presentation

In January 2019, a 16-year-old male was admitted to a local hospital after a five-story fall, presenting with life-threatening multisystem trauma. Initial assessment revealed hypotension (76/45 mmHg) and anemia [hemoglobin (Hb) 100 g/L]. While the patient remained conscious initially, he developed progressive hemorrhagic shock. Following emergency blood transfusion and fluid resuscitation for hemodynamic stabilization, he was transferred to the emergency department of The Second Affiliated Hospital of Shenzhen University. Due to active oropharyngeal hemorrhage, severe maxillofacial lacerations, and critical polytrauma, emergent endotracheal intubation was required during transport, indicating his precarious clinical status. Physical examination revealed active oral bleeding with severe maxillofacial lacerations, diminished right lung auscultation, open traumatic wounds involving the right knee and bilateral heels, gross hematuria, bilateral lower extremity hypoalgesia, and progressive hypotension. An emergency whole-body computed tomography (CT) demonstrated: descending aortic injury, bilateral pulmonary contusions, moderate left hemothorax, right pneumothorax, retroperitoneal effusion, right renal contusion with perinephric hematoma, skull base fracture, comminuted maxillofacial fractures, L3–L4 burst fractures with spinal canal compromise, sacral and bilateral calcaneal fractures, and severe open injuries to oral cavity, right knee, and bilateral heels. Further detailed imaging via computerized tomography angiography (CTA) exposed a critical finding: descending aortic injury with pseudoaneurysm formation (35.3 mm × 24.1 mm × 10 mm) originating 2 cm distal to the left subclavian artery (Figure 1A-1C). The patient’s aortic injury was classified as type III (pseudoaneurysm) according to the standard grading scheme. This finding highlighted the imminent risk of death from catastrophic bleeding.

Figure 1 Preoperative thoracic aorta computerized tomography angiography images. (A,B) Rupture of the thoracic aorta with pseudoaneurysm formation, measuring 35.3 mm × 24.1 mm × 10 mm; (C) preoperative three-dimensional reconstruction simulation image of the thoracic aorta.

Given the complexity and urgency of the patient’s condition, our trauma team implemented a prioritized management strategy: emergency TEVAR procedure. A multidisciplinary team in the emergency department performed an immediate wound debridement and temporary stabilization of open injuries. The patient was then immediately transferred to the operating room for TEVAR. Via a minimally invasive incision in the right femoral artery, a 6-F arterial sheath was carefully introduced. Aortography confirmed the presence of a descending thoracic aorta pseudoaneurysm. However, it did not provide clear visualization of the rupture site, in contrast to the diagnostic clarity achieved with prior CTA (Figure 2A). The proximal and distal diameters of the thoracic aorta at the site of the pseudoaneurysm measured approximately 18 mm. For the intervention, a stent-graft (ENEW2020C80EE, Medtronic Inc., Santa Rosa, CA, USA) was selected. This thoracic endograft was meticulously deployed using a delivery system and accurately positioned in the area distal to the left subclavian artery. Post-deployment angiography revealed excellent stent-graft wall apposition without endoleak formation. Importantly, the left subclavian artery ostium was completely unaffected (Figure 2B).

Figure 2 Aortography images. (A) Pre-stent deployment showing the pseudoaneurysm; (B) post-stent deployment showing the resolution of the pseudoaneurysm.

The TEVAR procedure was successfully performed, leading to a rapid recovery from the aortic injury without the need for antiplatelet therapy or spinal cord drainage. In the following course of treatment, the patient underwent a series of procedures across various specialties, including maxillofacial, orthopedic, and urologic surgeries, totaling 13 operations. Two weeks and 3 months after the TEVER, a vascular CTA scan further validated the absence of aortic dissection or pseudoaneurysm, with the graft appropriately seated and no indications of endoleak or infolding (Figure 3A-3C). Subsequently, we performed an annual imaging check. After 733 days, he made a full recovery and was discharged without any arterial injuries or postoperative complications. A follow-up period of up to 69 months indicated that the patient remained in good health, without any significant discomforts such as dyspnea, dizziness, headaches, or palpitations. The patient’s most recent CT image was acquired in September 2024 (Figure 4A,4B). However, the patient opted not to have a vascular CTA performed.

Figure 3 Post-operative thoracic aorta computerized tomography angiography images. (A,B) Follow-up postoperative computerized tomography angiography showing good apposition of the stent graft and resolution of the pseudoaneurysm; (C) postoperative three-dimensional reconstruction simulation image of the thoracic aorta.

Figure 4 Postoperative chest computerized tomography images (A,B) obtained at the 69-month follow-up.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient’s parent for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

BTAI in adolescent patients represents a rare but life-threatening condition, predominantly resulting from high-energy trauma mechanisms including motor vehicle collisions or significant-height falls, with a substantial number of fatalities occurring at the scene (1,7). The clinical management of adolescent BTAI presents particular challenges, as these injuries typically occur in conjunction with severe multisystem trauma—a factor that both complicates therapeutic decision-making and contributes to the elevated perioperative mortality rates associated with surgical repair (8,9). The three primary treatment strategies for BTAI include conservative observation, open surgery, and TEVAR. Given the frequent complexity and critical nature of these cases, optimal outcomes require coordinated multidisciplinary care involving trauma surgery, vascular surgery, critical care medicine, and other relevant specialties to carefully determine both the timing and sequencing of surgical interventions.

TEVAR, first approved by the U.S. FDA in 2005, has become the standard of care for BTAI in adult populations (8,10). Current Society for Vascular Surgery (SVS) clinical practice guidelines strongly recommend endovascular repair as the treatment strategy for adult BTAI (grades II–IV), demonstrating superior outcomes compared to both open surgical repair and nonoperative management. For grade I injuries, conservative management remains the recommended approach (11,12). The widespread adoption of TEVAR has precipitated a significant decline in open aortic procedures for trauma (13,14). A prospective multicenter observational study conducted by Demetriades et al. demonstrated superior outcomes with TEVAR compared to open repair in adult BTAI patients, including significantly lower mortality rates, reduced transfusion requirements, and decreased incidence of procedure-related paraplegia (15). Nevertheless, the rarity of BTAI in adolescent patients has resulted in a paucity of age-specific treatment guidelines. Substantial additional clinical evidence remains necessary to establish definitive consensus recommendations regarding TEVAR utilization in adolescent BTAI cases.

Open surgical repair remains the gold standard for treating BTAI in adolescent patients (16). However, the FDA has not yet cleared any endovascular device specifically indicated for traumatic aortic injury in pediatric populations. Hasjim et al. conducted a retrospective cohort study in 2019, analyzing 159 pediatric BTAI cases in the United States. They found that it is significantly prolonged hospital length of stay (LOS) and intensive care unit (ICU) LOS in open surgical patients compared to those undergoing TEVAR (11). However, no significant differences were observed in terms of mortality rates and in-hospital complications between the two groups. These findings suggest TEVAR may offer distinct advantages in pediatric BTAI management, particularly through reducing acute care resource utilization. This is a critical consideration for optimizing recovery in multiply injured pediatric patients (17).

The long-term outcomes and potential complications of TEVAR in adolescent patients remain a critical concern in vascular surgery. Current evidence regarding TEVAR for pediatric BTAI consists primarily of limited case reports and series (4-6), with most studies offer inadequate follow-up, or none at all, with an average follow-up duration of a mere 11 months. This paucity of long-term data raises important questions about TEVAR’s suitability for growing adolescents, particularly regarding possible developmental complications including aortic coarctation, stent graft migration, pseudocoarctation, device occlusion, and questions of long-term stent durability (6,16). Furthermore, the incidence and management of long-term sequelae following TEVAR for BTAI in adolescents remain essentially unexplored. Notably, no large-scale studies have systematically documented complications occurring beyond two years post-treatment. In this context, our 69-month follow-up of a 16-year-old BTAI patient—demonstrating complete aortic injury resolution without complications—provides encouraging but isolated evidence of TEVAR’s potential for favorable long-term outcomes in adolescents. This case underscores both the promise of endovascular repair and the imperative for rigorous multicenter studies with extended follow-up in adolescent patients periods to establish definitive guidelines.

While recognizing the anatomical and physiological distinctions between adolescent and adult patients, we maintain that TEVAR represents a viable first-line intervention for life-threatening BTAI in emergency situations. Furthermore, given that the physical development of adolescent patients is nearly at an adult level, the long-term outcomes of TEVAR in this age group are likely to be comparable. Although there remains a significant degree of uncertainty, the benefits of TEVAR for adolescents are substantial and gaining wider recognition. To definitively establish the safety profile and late complications of this treatment, comprehensive studies with extended follow-up periods are urgently needed. Such investigations should ideally incorporate detailed imaging surveillance and standardized outcome measures to properly evaluate stent-graft performance throughout patients’ continued growth and development.

Conclusions

The application of TEVAR for managing BTAI in adolescent patients is gaining momentum, though it remains a cautious adoption. TEVAR offers a comparatively manageable risk profile and favorable outcomes for adolescents with multiple traumas who are near-physiologically mature akin to adults. Nevertheless, further long-term surveillance is essential to comprehensively evaluate the durability and potential late-term complications of TEVAR in this patient demographic.

Acknowledgments

We would like to thank the patient and his parents for their support and cooperation in publishing this work.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-233/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-233/prf

Funding: This study was supported by Shenzhen High-level Hospital Construction Fund and Sanming Project of Medicine in Shenzhen (No. SZSM202411001).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-233/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient’s parent for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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